Clinical Rehabilitation 2009; 23: 504–511

Tai Chi Qigong for the quality of life of patients with knee osteoarthritis: a pilot, randomized, waiting list controlled trial Hwa-Jin Lee, Hi-Joon Park, Younbyoung Chae, Song-Yi Kim, Seung-Nam Kim, Seung-Tae Kim Acupuncture and Meridian Science Research Center (AMSRC), Kyung Hee University, Seoul and Department of Meridian and Acupoint, College of Korean Medicine, Kyung Hee University, Seoul, Je-Ho Kim Department of Rehabilitation Medicine, Hwaseong City Health Center, Chang-Shik Yin Acupuncture and Meridian Science Research Center (AMSRC), Kyung Hee University, Seoul and Hyejung Lee Acupuncture & Meridian Science Research Center (AMSRC), Kyung Hee University, Seoul and Department of Meridian and Acupoint, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea Received 11th September 2008; returned for revisions 24th October 2008; revised manuscript accepted 31st October 2008.

Objective: To evaluate the effects of Tai Chi Qigong training on the quality of life and physical function of patients with osteoarthritis of the knee. Design: A preliminary, single-blind, randomized controlled trial. Setting: General community, performed at Hwaseong City Health Center. Participants: Forty-four elderly subjects (mean age, 69.1  5.4 years) with knee osteoarthritis. Intervention: The patients were randomized (2:1) to: (1) an eight-week Tai Chi Qigong training programme or (2) a waiting list control group. The programme involved eight weeks of group Tai Chi Qigong sessions, with 60 minutes per session twice a week. Main outcome measures: The primary outcome was quality of life measured with the Short Form 36 (SF-36) at baseline and week 8. Secondary outcomes included the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and 6-m walking time. Results: The training group had statistically significant improvements in the quality of life (changes of SF-36, Qigong versus control: 21.6  16.8 versus 9.8  13.6, P50.05) and 6-m walking test (change in walking time, Qigong versus control: –1.6  1.7 versus –0.2  0.8 s, P50.01). The WOMAC scores in the training group were markedly improved, although the differences were not statistically significant. Conclusions: Tai Chi Qigong training appears to have beneficial effects in terms of the quality of life and physical functioning of elderly subjects with knee osteoarthritis. However, more rigorous trials are needed to confirm the efficacy of this training for patients with osteoarthritis of the knee.

Address for correspondence: Hyejung Lee, Acupuncture and Meridian Science Research Center (AMSRC), Kyung Hee University, 1 Hoegidong, Dongdaemungu, Seoul, 130-701, Republic of Korea. e-mail: [email protected] ß SAGE Publications 2009 Los Angeles, London, New Delhi and Singapore

10.1177/0269215508101746

Tai Chi Qigong for knee osteoarthritis

Introduction Osteoarthritis is one of the most prevalent chronic diseases worldwide.1 It is considered to be both a major cause of morbidity and a burden on healthcare resources.2 Patients with osteoarthritis display significant pain and functional limits,3,4 and they notice themselves as mentally and physically unhealthy.5 Although most study on osteoarthritis has mainly dealt with pain and physical disability, there is increasing interest in gauging the actualworld impact of osteoarthritis on patients through quality of life. The World Health Organization, the International League for Rheumatology Task Force,6 and the Osteoarthritis Research Society strongly recommend that quality of life measures be employed in osteoarthritis clinical research.7 Non-operative management tools for osteoarthritis, which include drug therapy8–12 and exercise regimens, such as aquatic exercise,13 strength training,14 and aerobic exercise, are emphasized by the medical community.15 As a low-impact, low-intensity alternative exercise therapy, Tai Chi Chuan has been proposed as a option for the management of osteoarthritis.16 Although several studies have shown some beneficial effects of Tai Chi Chuan for osteoarthritis,17–19 a recent systematic review revealed a lack of convincing evidence of pain reduction or improvement of physical function.20 Tai Chi Qigong was developed in the late 1970s, to simplify the movements of Tai Chi Chuan, and to combine its benefits with those of Qigong training, including incorporating intention into movement and enhancing awareness of breathing.21 Tai Chi Qigong consists of a sequence of 18 movements performed six times in a fluid and continuous manner, combined with deep abdominal breathing. Tai Chi Qigong is an easy and safe Qigong for patients because it is simpler and more repetitive than other types of Tai Chi Chuan. Tai Chi Qigong is especially suitable for patients with joint problems, as the motion does not impose undue pressure on the pivot joints, such as the waist, knees and ankles during training. Based on these features, Tai Chi Qigong training has been suggested an alternative therapy to improve the physical functioning and quality of life of patients with osteoarthritis of the knee.

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The objective of the present study was to evaluate whether Tai Chi Qigong training has beneficial effects on the quality of life of patients with osteoarthritis of the knee.

Methods This study was a randomized, controlled, eightweek prospective trial with two groups of patients. The participants were randomized 2:1 to a training group and a waiting list control group using computer-generated balanced block randomization. A sealed envelope with an identification number was assigned to each subject, each one filled with a slip giving the group. When a patient was screened and given a number, the appropriate envelope was opened. The assessors were blinded to the participants’ treatment assignments. All patients gave informed consent for the study. This investigation was approved by the Ethics Committee of Acupuncture and Meridian Science Research Center, Kyung Hee University, Seoul, Republic of Korea.

Patients Patients were recruited from the Hwaseong City Health Center, Republic of Korea. The inclusion criteria were as follows: (1) symptomatic osteoarthritis with radiologic alterations in the knee joint of grade 2 or higher (Kellgren–Lawrence Scale) at least six months prior to study entry, (2) no current participation in an exercise programme; and (3) 50–80 years of age. The exclusion criteria applied to patients who: (1) had received a corticosteroid injection in the symptomatic knee within six months of study entry; (2) had received medication for osteoarthritis within six months; and (3) had a history of knee surgery or a prior diagnosis of inflammatory arthritis.

Interventions Tai Chi Qigong was performed for 1 hour, and repeated twice a week for eight weeks. Tai Chi Qigong consists of 18 movements, in which traditional warm-up exercises include weight shifting, arm swinging, visualization techniques and gentle

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Table 1

The Tai Chi Qigong sequence

Activities

Approximate Duration (min)

Warm-up exercise 1) Supine – hypogastric breathing 2) Sitting – neck/shoulder stretches 3) Sitting – arm/leg stretches

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Tai Chi Qigong 18 movements: 1) Raising the arms 2) Opening the chest 3) Painting a rainbow 4) Separating the clouds 5) Rolling the arms in a horse-riding stance 6) Rowing the boat 7) Carry ball in front of the shoulders 8) Looking at the moon 9) Pushing palms 10) Cloud hands in a horse-riding stance 11) Scooping the sea and searching the sky 12) Pushing waves 13) Flying dove spreads its wings 14) Punching in horse stance 15) Flying like wild geese 16) Rotating wheel 17) Stepping whilst bouncing a ball 18) Balancing chi

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stretches of the neck, shoulder spine, arms and legs. These exercises focus on releasing tension in the physical body, incorporating mindfulness and imagery into movement, increasing awareness of breathing and promoting overall relaxation of the body and mind. The Tai Chi Qigong sequences are described in Table 1. The control group received no intervention during the study period. After the intervention study, the control group was offered the same training programme as the treatment group.

Physical function was quantified using the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) questionnaire, with a scale from 26 (no difficulty) to 130 (extreme difficulty) indicating the level of difficulty associated with overall functional activities due to knee pain, and including subscales for knee pain (35 points), stiffness (10 points) and physical function (85 points).23,24 The WOMAC scoring system has proven to be a valid and reliable tool for use in patients with osteoarthritis of the knee.25,26 To evaluate the physical functioning of the osteoarthritis patients, we used the 6-m walking test. Patients were instructed to walk a distance of 6 m as fast as possible and the elapsed time was recorded.

Statistical analysis The values are expressed as the mean  standard deviation (SD). Analysis was performed on the 44 participants who were randomized for the intention-to treat analysis using the ‘last score carried forward’ technique. The primary analysis was based on general linear models, with the outcome measures applied as dependent variables. Each analysis of an individual patient’s baseline level was used as a covariate in the corresponding one-way analysis of covariance (ANCOVA). Independent t-test was additionally used to compare the changes of the scores between two groups. Differences were considered statistically significant at P50.05. Statistical analysis was performed using the Statistical Package for Social Sciences for Windows version 12.0 (SPSS Inc., Chicago, IL, USA).

Results Outcome measurements The outcome variables were measured at the baseline and eight weeks. The Short Form 36 (SF-36) Health Survey was used as a primary outcome measure of the health status of the participants.22 This measure consists of 36 items rated on Likert scales, wherein the items are summed and then transformed to yield a total score that ranges from 0 to 100, with higher scores indicating more favourable health.

The study was carried out from February to July 2008. The study population had a mean age (SD) of 69.1 (5.4) years, and were mostly female (93%). The baseline characteristics of the patients are presented in Table 1. The baseline characteristics were not significantly different between the Tai Chi Qigong training group and the waiting list control group (Table 2). Twenty-eight patients in the training group and 13 patients in the control

Tai Chi Qigong for knee osteoarthritis Table 2

Demographic and baseline characteristics

Characteristics

Tai Chi Qigong (n ¼ 29)

Waiting list (n ¼ 15)

Age 70.2 (4.8) 66.9 (6.0) Male sex 2 (6.9%) 1 (6.7%) Weight (kg) 61.3 (10.3) 59.1 (5.9) Height (cm) 153.2 (6.3) 150.9 (6.6) BMI 26.0 (3.8) 26.0 (2.8) Kellgren-Lawrence grade, n (%) Grade 2 14 (41.4%) 8 (53.3%) Grade 3 13 (44.3%) 7 (46.7%) Grade 4 2 (6.9%) 0 SF-36 Total 42.9 (14.7) 45.3 (13.4) Physical Health 38.7 (14.1) 40.0 (11.9) Mental Health 48.0 (17.1) 43.4 (11.4) WOMAC Total 33.6 (20.2) 31.8 (17.4) Pain 6.8 (4.2) 6.1 (3.4) Stiffness 2.7 (2.0) 2.1 (1.7) Physical function 24.2 (14.7) 23.5 (13.4) 6-m walking time (s) 7.5 (1.8) 7.0 (1.7)

P-value 0.082 0.388 0.282 0.770

0.605 0.755 0.352 0.768 0.623 0.360 0.889 0.341

Values are shown as mean  SD unless stated otherwise, and analysed by independent t-test. SF-36, 36-Item Short-Form Health Survey; WOMAC, Western Ontario and McMaster University Osteoarthritis Index.

group (each P ¼ 0.018 ANCOVA) (Table 3).

and

P ¼ 0.030,

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Secondary outcome measures The Tai Chi Qigong group showed improvements in total WOMAC score compared with the control group (qigong versus control: 20.8  18.7 versus 28.5  19.6, P ¼ 0.086 by ANCOVA). The subscales of pain, stiffness and physical function showed similar trends with total WOMAC score (each P ¼ 0.088, P ¼ 0.300, P ¼ 0.095 by ANCOVA). When we compared the differences in the data from baseline to eight weeks between groups, the significant improvements appeared only in the pain subscales (Qigong versus control: –2.2  4.1 versus 0.2  1.8, P ¼ 0.030 by independent t-test). In the 6-m walking test, the Tai Chi Qigong group spent significantly shorter times (Qigong versus control: 5.9  1.0 versus 6.7  1.8 seconds, P ¼ 0.005 by ANCOVA) (Table 4).

Discussion group completed the final examinations and questionnaires. During the course of the trial one female patient in the training group was withdrawn from the study protocol due to the professional activities not related to her clinical condition. One woman withdrew because she moved to another place and one with no reason given (Figure 1). Primary outcome measures We compared the changes in quality of life for each group before and after the eight-week training programme. The Tai Chi Qigong group showed significant improvements in the total SF-36 score compared with the control group (Qigong versus control: 64.4  20.9 versus 55.1  17.5, P ¼ 0.010 by ANCOVA). The proportion of responders (patients with a changes of at least 50% in their SF-36 scores was 59% in the Qigong group compared with 27% in the control group. On all the subscales (mental and physical components), the Qigong group showed significant improvements compared with the control

In this study we focused on the evaluation of the quality of life of osteoarthritis patients in the general community, and we found that Tai Chi Qigong training confers beneficial effects on elderly patients with knee osteoarthritis in terms of improving their quality of life and physical functioning. There has been some controversy as to whether or not Tai Chi Chuan improves the quality of life of osteoarthritis patients.27 Two studies using quality of life as secondary outcomes did not show improvements in the SF-12 or SF-36, compared with hydrotherapy or a waiting list control group.16,28 However, our study shows that Tai Chi Qigong improves both the mental and physical health of osteoarthritis patients, as measured by the SF-36. In the present study, Tai Chi Qigong training generated a 38% improvement in WOMAC score, although the differences between the Tai Chi Qigong group and the control group were not statistically significant. Since changes of 20–25% in WOMAC score are considered

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Recruitment (n = 60)

Exclusion (n = 16) Over age (n = 2) Knee surgery (n = 2) Kellgren grade